Terminal care: present services and future priorities.

Since 1975 hospices and other specialist services for terminal cancer have expanded rapidly. In December 1980 this survey found 72 such services in Britain providing 58 inpatient units, 32 home care teams, and eight hospital support teams. Many were outside the NHS. Inpatient units provided 1297 beds (modal size 21-25 beds) and dealt with under 7% of deaths from cancer. Home care teams provided 76.5 full-time equivalent nurses (modal size two nurses). Regional variations were considerable: from 10.9 beds/million population in Trent to 48.5 beds/million in South-west Thames; no home care nurses in Mersey and Wales, and 5.1 nurses/million in Wessex. Of 58 more services being planned, the 17 starting in 1981 will not substantially alter these regional imbalances. Respondents'' opinions suggest a target of 40-50 inpatient unit beds/million population. This might be reduced if hospitals were better equipped to deal with these patients. Suggested priorities are to redress regional inequalities, develop home care and hospital support teams rather than inpatient units, and improve teaching and training. Co-ordination of plans between the NHS and the voluntary sector is needed.     

Dispersal of aquatic organisms by waterbirds: a review of past research and priorities for future studies

1. Inland wetlands constitute ecological islands of aquatic habitat often isolated by huge areas of non-suitable terrestrial habitats. Although most aquatic organisms lack the capacity to disperse by themselves to neighbouring catchments, many species present widespread distributions consistent with frequent dispersal by migratory waterbirds.
2. A literature review indicates that bird-mediated passive transport of propagules of aquatic invertebrates and plants is a frequent process in the field, at least at a local scale. Both endozoochory (internal transport) and ectozoochory (external transport) are important processes.
3. The characteristics of the dispersed and the disperser species that facilitate such transport remain largely uninvestigated, but a small propagule size tends to favour dispersal by both internal and external transport.
4. We review the information currently available on the processes of waterbird-mediated dispersal, establishing the limits of current knowledge and highlighting problems with research methods used in previous studies. We also identify studies required in the future to further our understanding of the role of such dispersal in aquatic ecology.     

Rice-maize systems of South Asia: current status, future prospects and research priorities for nutrient management

Rice (Oryza sativa L.) and maize (Zey mays) are grown in 3.5 million hectares (Mha) in Asia that includes 1.5 Mha in South Asia. These crops are grown in sequence on the same land in the same year either in double–or triple-crop systems to meet the rice demand of a rapidly expanding human population and maize demand of livestock and poultry. The objective of this review is to provide a comprehensive overview of the current state of technical knowledge on agro-ecosystems and adaptation, area and distribution, yield potential and yield gaps, and nutrient management for rice-maize (R-M) systems in South Asia. Rice-maize systems are emerging all around South Asia but in particular are developing quite rapidly in Bangladesh and South and North India. Yield potential of rice and maize, as estimated by ORYZA2000 and Hybrid Maize models, reaches up to 15 and 22 t ha^-1, respectively. However, data from several environments in India reveal gaps between potential and attainable yields of maize of upto 100% and between attainable and actual yields of upto 25–50%. Nutrient demand of R-M system is high due to high nutrient removal by high-yielding maize. Nutrient balance studies for these highly–productive and nutrient-extractive systems are scarce in South Asia. The review outlines principles of nutrient management for R-M systems, and identifies development, refinement, and dissemination of the integrated plant nutrition system technologies based on site-specific nutrient management principles as priorities for future research to increase yield, profitability, and sustainability of R-M systems.     

Older women's health priorities and perceptions of care delivery: results of the WOW health survey

BackgroundAs women get older, their health priorities change. We surveyed a sample of older Canadian women to investigate what health priorities are of concern to them, their perceptions about the care delivered to address these priorities and the extent to which priorities and perceptions of care differ across age groups and provinces.MethodsThe WOW (What Older women Want) cross-sectional health survey was mailed in October 2003 to 5000 community-dwelling women aged 55–95 years from 10 Canadian provinces. Women were asked questions on 26 health priorities according to the World Health Organization''s International Classification of Functioning, Disability and Health, and their perceptions of whether these priorities were being addressed by health care providers through screening or counselling. Differences in priorities and perceptions of care delivery were examined across age groups and provinces.ResultsThe response rate was 52%. The mean age of the respondents was 71 (standard deviation 7) years. The health priorities identified most frequently by the respondents were preventing memory loss (88% of the respondents), learning about the side effects of medications (88%) and correcting vision impairment (86%). Items least frequently selected were counselling about community programs (28%), counselling about exercise (33%) and pneumonia vaccination (33%). Up to 97% of the women recalled being adequately screened for heart disease and stroke risk factors, but as little as 11% reported receiving counselling regarding concerns about memory loss or end-of-life issues. Women who stated that specific priorities were of great concern or importance to them were more than twice as likely as those who stated that they were not of great concern or importance to perceive that these priorities were being addressed: osteoporosis (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.1–3.2), end-of-life care (OR 2.6, 95% CI 2.0–3.4), anxiety reduction (OR 2.2, 95% CI 1.8–2.6), fall prevention (OR 2.1, 95% CI 1.6–2.7), stroke (OR 2.1, 95% CI 1.4–3.0), depression (OR 2.1, 95% CI 1.7–2.7) and urinary incontinence (OR 2.1, 95% CI 1.7–2.5). The respondents'' perceptions of care delivery varied across age groups and provinces.InterpretationAccording to the perceptions of surveyed women, health care providers are addressing many, but not all, of their health concerns, especially those that are of great concern or importance to these women.As women''s life expectancy increases, physicians are confronted with the challenge of treating an elderly population that is predominantly female and has a variety of health priorities and needs. Older women face functional, psychological and social difficulties in addition to health-related conditions. One solution to align care more closely with women''s health priorities is to practise patient-centred care, whereby clinical decision-making is focused primarily on the priorities and preferences of individual patients.^1,2,3 Data on older women''s health priorities are scarce,^4,5,6 and understanding the gamut of their concerns is important for directing patient-centred, priority-driven agendas. The WOW — What Older women Want — health survey was conducted to determine health priorities of older Canadian women and the extent to which women perceive that their priorities are being addressed by health care professionals.     

Bryophytes of Sri Lanka: a review of past exploration and taxonomic research and priorities for the future

This overview presents a historical summary of the past collectors of bryophytes (mosses, liverworts and hornworts) in Sri Lanka, formerly Ceylon, and some of the researchers who studied and published the results of their explorations. The first British collectors of the early nineteenth century were linked with the development of the Botanic Garden and herbarium in Peradeniya, of which George Gardner and George Thwaites made the greatest contributions, resulting in three publications by William Mitten on both mosses and liverworts. By the mid-nineteenth century, collectors from other countries took the lead, firstly Johannes Nietner from Germany and Odoardo Beccari from Italy. By the early twentieth century, Victor Schiffner from Austria and Max Fleischer from Germany became the leading bryologists throughout SE Asia, and both visited Ceylon. Fleischer’s work was part of a monographic revision of all mosses resulting in many new genera and species. After Fleischer, the most important bryologist was the German Theodor Herzog, who was the first to describe the ecological structure and bryological richness of different forest zones in southern Ceylon, with insight into forest loss from agricultural and population expansion, and a summary of biogeographical links of the bryoflora. The English bryologist H.N. Dixon took over from Mitten in describing many new moss species. Since independence in 1948, bryology in Sri Lanka has had major input from some local bryologists, such as B.A. Abeywickrama, as well as several important visitors, notably H. Inoue from Japan, C.C. Townsend from England, P.P.M. Tixier from France, and Maurice Onraedt from Belgium. Awareness in Sri Lanka of the need to taxonomically revise the extensive and scattered herbarium collections, has led to the running of some bryophyte workshops and training of new Sri Lankan bryologists. The ultimate goal of these efforts is to produce the first comprehensive bryophyte flora of the country, and priorities for future work are outlined.     

Use of consensus development to establish national research priorities in critical care

ObjectivesTo test the feasibility of using a nominal group technique to establish clinical and health services research priorities in critical care and to test the representativeness of the group''s views.DesignGeneration of topics by means of a national survey; a nominal group technique to establish the level of consensus; a survey to test the representativeness of the results.SettingUnited Kingdom and Republic of Ireland.SubjectsNominal group composed of 10 doctors (8 consultants, 2 trainees) and 2 nurses.ResultsOf the 325 intensive care units approached, 187 (58%) responded, providing about 1000 suggestions for research. Of the 106 most frequently suggested topics considered by the nominal group, 37 attracted strong support, 48 moderate support and 21 weak support. There was more agreement after the group had met—overall mean of the mean absolute deviations from the median fell from 1.41 to 1.26. The group''s views represented the views of the wider community of critical care staff (r=0.73, P<0.01). There was no significant difference in the views of staff from teaching or from non-teaching hospitals. Of the 37 topics that attracted the strongest support, 24 were concerned with organisational aspects of critical care and only 13 with technology assessment or clinical research.ConclusionsA nominal group technique is feasible and reliable for determining research priorities among clinicians. This approach is more democratic and transparent than the traditional methods used by research funding bodies. The results suggest that clinicians perceive research into the best ways of delivering and organising services as a high priority.     

Realities for change in child health care: existing patterns and future possibilities.

In assessing some of the existing patterns and future possibilities in child health care it was found that the continuing large social class differences in morbidity and mortality may be attributed to continued poverty, both of income and therefore of diet, and also to environmental deprivation. The absence of safe places for children to play, for example, is related to the high accident rates experienced by children. Doctors admit to awareness of these social and environmental causes of unnecessary morbidity and mortality among children but have failed to address the causes directly. While the causes are outside the immediate professional provenance of doctors, it is argued that, aware as they are of this aetiology, they have a moral and professional responsibility to act collectively as a pressure group urging improvements on the relevant authorities (as they have done in the case of smoking and clean air, for example).     

Defining priorities for improving end-of-life care in Canada

Background

High-quality end-of-life care should be the right of every Canadian. The objective of this study was to identify aspects of end-of-life care that are high in priority as targets for improvement using feedback elicited from patients and their families.

Methods

We conducted a multicentre, cross-sectional survey involving patients with advanced, life-limiting illnesses and their family caregivers. We administered the Canadian Health Care Evaluation Project (CANHELP) questionnaire along with a global rating question to measure satisfaction with end-of-life care. We derived the relative importance of individual questions on the CANHELP questionnaire from their association with a global rating of satisfaction, as determined using Pearson correlation coefficients. To determine high-priority issues, we identified questions that had scores indicating high importance and low satisfaction.

Results

We approached 471 patients and 255 family members, of whom 363 patients and 193 family members participated, with response rates of 77% for patients and 76% for families. From the perspective of patients, high-priority areas needing improvement were related to feelings of peace, to assessment and treatment of emotional problems, to physician availability and to satisfaction that the physician took a personal interest in them, communicated clearly and consistently, and listened. From the perspective of family members, similar areas were identified as high in priority, along with the additional areas of timely information about the patient’s condition and discussions with the doctor about final location of care and use of end-of-life technology.

Interpretation

End-of-life care in Canada may be improved for patients and their families by providing better psychological and spiritual support, better planning of care and enhanced relationships with physicians, especially in aspects related to communication and decision-making.Although a “quality death” is an espoused right of Canadians,¹ for many dying patients and their families, it is not achieved. Recent reviews and observational studies describe considerable dissatisfaction with end-of-life care, indicating that there are still opportunities for improvement.^2–5Ideally, initiatives aimed at improving end-of-life care would be informed by the experiences and expectations of patients and their family members. However, such efforts are often hampered by inadequate definitions of quality of care and by suboptimal tools for measurement.^6–8 In a recent, large cross-sectional survey, the Canadian Researchers at the End of Life Network defined what matters most to seriously ill patients as they approach the end of life.⁹ Both patients and their family members reported that it was extremely important that they have trust and confidence in the physicians caring for them or their loved ones.⁹ Avoidance of unwanted life-support measures, effective communication, continuity of care, and feelings of life completion were also rated as highly important.⁹ We used these comprehensive ratings of importance to develop and validate a novel questionnaire to measure satisfaction with end-of-life care.¹⁰ Using this questionnaire, we formally evaluated the care received at the end of life in several Canadian centres.By targeting initiatives for change at gaps in quality, we can address the highest priorities for improving end-of-life care in Canada. Our objective was to identify high-priority areas for improvement in the care of patients with advanced, life-limiting diseases and in the perceived quality of that care by their families. We identified these areas by focusing on care-related issues that had been rated as important by patients and their family members but were rated low on the questionnaire measuring satisfaction with end-of-life care.     

Developments for a growing Japanese patient population: facilitating new technologies for future health care

Lung cancer, COPD and cardiovascular diseases are highlighted as some of the most common disease that cause mortality, and for that reason are the most active areas for drug development. This perspective paper overviews the urgent need to develop a health care system for a rapidly growing patient population in Japan, including forthcoming demands on clinical care, expecting outcomes, and economics. There is an increasing requirement to build on the strengths of the current health care system, thereby delivering urgent solutions for the future. There is also a declaration from the Ministry of Health, Labour and Welfare (MHLW), to develop new biomarker diagnostics, which is intended for patient stratification, aiding in diagnostic phenotype selection for responders to drug treatment of Japanese patients. This perspective was written by the panel in order to introduce novel technologies and diagnostic capabilities with successful implementation. The next generation of personalized drugs for targeted and stratified patient treatment will soon be available in major disease areas such as, lifestyle-related cancers, especially lung cancers with the highest mortality including a predisposing disorder chronic obstructive pulmonary disease, cardiovascular disease, and other diseases. Mass spectrometric technologies can provide the "phenotypic fingerprint" required for the concept of Personalized Medicine. Mass spectrometry-driven target biomarker diagnoses in combination with high resolution computed tomography can provide a critical pathway initiative facilitated by a fully integrated e-Health infrastructure system. We strongly recommend integrating validated biomarkers based on clinical proteomics, medical imaging with clinical care supported by e-Health model to support personalized treatment paradigms to reduce mortality and healthcare costs of chronic and co-morbid diseases in the elderly population of Japan.